4/20/2020 1 COVID-19 Coding applications Sheila Goethel, RHIT, CDIP, CCS April 2020 PPT availability and Archive Viewing Instructions • PPT handout will be available on archived link – click on the paperclip icon • Complete survey to obtain CEU form • Link to view taped session will be available at: – http:// www.rwhc.com/Resources/PublicPresentations.aspx (RWHC Resources) – https ://www.whima.org/continuing-education/ WHIMA Education as well as through KnowledgeConnex – https ://www.whainfocenter.com/ (WHAIC website) – https:// www.wha.org/On-demandLearning (WHA On-Demand learning center)
Transcript
4/20/2020
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COVID-19Coding
applications
Sheila Goethel, RHIT, CDIP, CCS
April 2020
PPT availability and Archive Viewing Instructions• PPT handout will be available on archived link – click on the
paperclip icon
• Complete survey to obtain CEU form
• Link to view taped session will be available at:
Sequencing and use of B97 code is now outdated!!Did not include CM code newly effective U07.1
Effective April 1 2020
• Index and Tabular https://www.cdc.gov/nchs/data/icd/icd-10-cm-april-1-2020-addenda.pdf
• FAQs released in late March https://www.codingclinicadvisor.com/faqs-icd-10-cm-coding-covid-19?utm_source=email&utm_medium=eblast&utm_campaign=CovidWebsite03242020&utm_term=maintext&mkt_tok=eyJpIjoiWm1WaU1HRTFNVFl3WmpZMiIsInQiOiJ0VVRMYkpQTFlSaW03WjRNMDVYdXBZQ1wvUW5Sbzl4M1pBbjNYMHNmeDBvNGhMOEl0V2FJMGp0ZSs4andvTGg1RTFzK1BXZWkyQWV2dFFqcElSWVZ2RWRnMmd2bkVqcmViNHQ0bHYydWg1ZVk3bDVCMExwUG41OXFpV1kxOGFBRGoifQ%3D%3D
• No other CM codes (i.e. testing, exposure) have been added at this time
• Sequencing will depend on the circumstances of the encounter (will typically be principal/first listed)
• Entire Guidelines will be utilized in sequencing decisions
• Coding is based solely on providers documentation – not on positive lab test result
Screening GuidelinesSection I.C.21.c.5
• “Screening is the testing for disease ……in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease….
• The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
• A screening code may be a first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.”
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Screening for COVID-19
• Screening – testing without S/S –Z11.59
• Seemingly healthy individuals walking into a clinic or ER will not automatically be tested.
• Patients calling/presenting for testing will be thoroughly vetted.
• This vetting process/triage will weed out those that are not at risk.
• Classified through DHS as a non-priority patient
• We don’t expect “screening” to occur for COVID at this time…perhaps in the future
Observation to rule out GuidelinesSection I.C.21.c.6
• “….when a person is being observed for a suspected condition that
is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.
• The observation codes are to be used as principal diagnosis only.… Additional codes may be used in addition to the observation code, but only if they are unrelated to the suspected condition being observed.”
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Observation for COVID-19Possible Exposure
• Observation without S/S –Z03.818
• Coded when condition was RULED OUT after testing
• Patient has possible exposure that warrants testing for COVID.
• May occur when Inpatient transitions back to the SNF (Part B stay) and SNF request COVID test to ensure staff or clients are not at risk
• “Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic.”
• NEW GUIDELINES…”For cases where there is an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the exposed individual either tests negative or the test results are unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. If the exposed individual tests positive for the COVID-19 virus, code U07.1.
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NEW EXCEPTION!!
If a patient with signs or symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828 (contact with and (suspected) exposure to other viral communicable diseases), as an additional code. This is an exception to Guideline I.C.21.c.1 Contact/Exposure.[!!]
• Patient reports suspected exposure to neighbor
• Patient complains of runny nose and cough
• Test result is negative
Example #1 Example #2
• Patient reports exposure to husband who has reported positive
is reported even though Guidelines instruct this is only reported when no S/S are present.
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Observation versus ExposureSymptoms Yes NO Yes No Yes
ExposureNo exposure or
any risk documented
Suspected Contact
Suspected Exposure or
Contact
Known or Suspected
Exposure or Contact
Known Exposure or
Contact
Lab Test Performed
Yes Yes Yes Yes Yes
Test Results Negative Negative Negative Negative Negative
Code(s) Symptoms Z03.818Symptoms +
Z20.828Z20.828
Symptoms + Z20.828
What happens if the S/S are due to an established condition?
• “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification… If a patient with signs/symptoms associated with COVID-19 also has an actual or suspected contact with or exposure to someone who has COVID-19, assign Z20.828 (Contact with….) as an additional code. This is an exception to guideline I.C.21.c.2,Contact/Exposure….”
ER encounter example – patient enters with cough and fever and shares that family member in same household has been tested positive for COVID. Therefore, COVID lab test ran and results were negative. After exam, Impression denotes:
1. Acute Bronchitis with exposure to COVID-19
2. Code: J20.9 & Z20.828
NEW GUIDELINES and FAQ
“Codes should be assigned for the condition (e.g., flu, pneumonia) and code Z20.828 should be assigned as an additional diagnosis.”
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TESTING POSITIVE – U07.1
CM Coding for COVID-19
• New Guidelines support…“If the provider documents “suspected”, “possible”, “probable” or “inconclusive” COVID-19, do not assign code U07.1. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828, Contact with and (suspected) exposure to other viral and communicable diseases” [for all encounter types].
• Like HIV and avian or other novel viruses, coding will be based on the provider's diagnostic statement that the patient has positive Coronavirus/COVID-10
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Guidelines Also Support Presumptive positive COVID-19 tests results are coded as confirmed. Emphasize presumptive positive – This directive is based on Physician documentation regarding a Presumptive positive lab test – and not a possible diagnosis of the condition.
AHA Coding Clinic Advisor – FAQ – link on reference page
AHA Coding Clinic Advisor – FAQ – link on reference page
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Clinical Indicator Query
• Documentation reveals COVID-19 diagnosis without having a lab report to support diagnosis
• Result returned negative
• Physician documents and confirms COVID-19 diagnosis even with a negative test result available
• Recommendation: Query provider to validate
• Recommendation: Assign U07.1
Sequencing – U07.1 as First versus Secondary
Maintain Convention and Guideline directives
First
When it meets definition of principal/first listed
Conventions Direct
Second
When other Guidelines instruct
e.g. OB and Sepsis
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Index Entry – Effective 4-1-20
Index Entry – Effective 4-1-20
CM Coding• B97.29 (other coronavirus as the cause of diseases classified elsewhere)
– Reported as secondary code PRIOR to 4-1-20
– Is NOT exclusive to the SARS-CoV-2/2019-nCoV virus responsible for the COVID-19 pandemic
– (Like bacterial UTIs) These codes are supplementary or additional.
• B34.2 (coronavirus infection unspecified)
– Not coded for COVID-19 as COVID is respiratory in nature…so COVID-19 IS “specified”
4-1 Tabular addenda
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Tabular Entry – Effective 4-1-20
“Use additional code” is located at etiology code“Code First” is located at the manifestation code
Inpatient ExamplePatient admitted with SOB, fever, and coughing. CXR confirmed pneumonia & lab tests reveal COVID-19 positive. Patient monitored in ICU for one day, but did not display any signs of respiratory failure or hypoxemia. Received IV antibiotics. D/S reveals a viral pneumonia due to COVID-19.
Inpatient Example• Patient falls down the stairs at home and is admitted with a broken
RT femur and RT radius. Required surgery for both fxs. On the second day, patient confides neighbor has been struggling for 5 days with COVID related symptoms including fever, cough and SOB. Patient indicates he visited twice last week to deliver meals to this individual. Patient therefore tested – test positive, but was not symptomatic nor treated for COVID during his 5 day stay.
Code: 1) Fx
2) U07.1
CC 3rd Q ‘16 informs to report A41.89 (Other specified sepsis) and B97.89
(other viral agents) for “Viral Sepsis”
In this case, B97.29 (Other coronavirus as cause of diseases classified
elsewhere) is more applicable than B97.89 to represent the viral agent
Sepsis guidelines Section I.C.1.d.4 provides sequencing as follows: “If the reason for admission is sepsis or severe sepsis and a localized infection, such as
pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. ..”
D/S denotes Sepsis with Viral Pneumonia due to COVID-19: A41.89
Modifier CS recently introducedFamilies First Act – Effective March 18th, 2020
• Modifier CS appended onto EM when visit results in COVID lab test – Office/Outpt visits, ER, Hosp OBS, Nursing facility and custodial services, home health, and online digital
EMs
– Not clear if only reported when COVID lab ordered (87365, U0001 or U0002) OR if also includes CXR or other labs that were ordered for MDM
• Professional or Institutional modifier
• Waives cost sharing (coinsurance and deductible) for Medicare patients
– Provider is paid 100%
– Many third party payers have also requested this modifier
• If already submitted claim without Modifier CS:
– Pro – notify NGS and request to resubmit
– Institutional/Hospital - resubmit
?? ER patientQ: A patient presents with cough/fever and diagnosed with an influenza like illness. The patient was tested for COVID-19, which was negative. Encoder is giving and edit that Z03.818 should be primary, but the patient did not present specifically for COVID-19 testing. Should we bypass this edit?
Answer/Rationale: Guidelines indicate to report the S/S when no definitive diagnosis of COVID-19 is made. As previously mentioned, we have an Exception now to report Z20.828 as SECONDARY when there is suspected/actual exposure. Without any risk or (suspected) exposure documented, recommend to report:CODE: R05 (cough), R50.9 (fever) – Facility and Pro: 9928X-CS & 87635
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?? ER setting
Q: Patient presents with reported exposure to co-worker that tested positive yesterday. Patient complained of fever – tested and test result was negative.
Answer/Rationale: Guidelines indicate to report the S/S when no definitive diagnosis of COVID-19 is made. Guideline Exception now advises to report Z20.828 as SECONDARY when there is suspected/actual exposure.
1. R50.9 (fever), 2. Z20.828 (exposure) is also reported, as Exception to the Guidelines allow to report as secondary even though s/s were present.
Facility and PRO EM: 9928X-CS & 87365
?? Inpatient settingQ: What if a patient is diagnosed with pneumonia due to COVID-19 but all the documentation says probable and the test result isn't in yet? Or what if the test comes back negative? Would it just be coded as pneumonia then?
Answer/Rationale: Possible/probable COVID dx documented at discharged cannot be reported even on inpatient. Coder needs to have provider documentation that supports a (positive) test/diagnosis. AHA Q&A advises to wait for COVID test result for coding functions and to query provider to validate COVID-19 diagnosis. Therefore, wait for COVID test result to return and query physician (as necessary) to document test result into inpatient account.
Code: Code assignment will rely on lab test result and query response.
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?? LTC/SNF facility questionQ: Our facility is partnered with a large local hospital and there is talk of taking displaced people for possible exposure for their quarantine period without having them be picked up skilled for therapy. This is where the Z20.828 would come into play correct? But, PDPM says that is return to provider. Does the disaster relief condition code make Z20.828 an acceptable primary diagnosis for SNF even though PDPM says it's return to provider? In the MDS should SOB be documented on COVID-19 patients like it is in COPD patients to paint the whole picture (dyspnea lying flat for example) and ensure maximum reimbursement?
?? LTC/SNF facility questionAnswer/Rationale: Without knowing specifically:
1) If you are using your SNF as a temporary expansion site of the hospital, (allowed by waiver), I expect this will be billed on the hospital bill.
2) If you are asking how to report those individuals that need to come back to the SNF but under a 14 day quarantine period, the patient is just going into a quarantine area – and not actually in SNF for quarantine or Observation to rule out a condition. As they are in the SNF for a designated skilled reason – would recommend to report that CM code for PDPM and utilize Obs vs Exposure grid for secondary.
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Other Tools & References
• AHIMA query templates – both specificity and validatationhttps://ahima.realmagnet.land/covid-19-query-templates-professional
